CARDIOLOGY DOCTORS IN HOSUR ROAD
This is not quite a cardiac condition and not quite a respiratory condition but it is often managed
by cardiologists. Modern CT pulmonary angiography is very sensitive and specific for
the diagnosis of PE. A negative scan that is of good quality effectively excludes the diagnosis.
The scans are so sensitive that small distal emboli may be detected in patients who do not have
convincing symptoms of embolism. This poses a therapeutic problem that may be avoided if
scans are not ordered inappropriately.
Some patients cannot have a CTPA, usually because of renal impairment that would make
the injection of contrast risky. A V/Q nuclear scan is then a reasonable alternative to a CTPA.
These scans are less accurate than CT pulmonary angiography but the clinical suspicion of PE
and a lung scan reported as intermediate or high probability is an indication for treatment.
Patients should be admitted to hospital and treatment begun with intravenous heparin or
subcutaneous low molecular weight heparin. The latter has the advantage that the dose is determined
by body weight and repeated measurements of clotting times are not required. In some
cases it may be possible to treat patients with small pulmonary emboli at home with supervised
low molecular weight heparin. Either way, soon after diagnosis patients should be started on
oral anticoagulation treatment with warfarin. A stable INR may often be achieved within five
days or so, the heparin ceased and the patient discharged. Most patients with dyspnoea as a
result of PE begin to feel better within a few days of starting treatment.
It is often difficult to know how long to continue treatment with warfarin. The usual recommendation
for an uncomplicated first PE is three to six months. Recurrent PE may be an
indication for lifelong treatment. It also suggests a need to investigate for clotting abnormalities
(e.g. anti-thrombin III deficiency, protein S and protein C deficiency, abnormal Factor V and
A very large and life-threatening PE which is associated with the sudden onset of severe dyspnoea
and hypotension may be an indication for thrombolytic treatment. An echocardiogram
may show abnormal right ventricular function in these ill patients and help in the decision.
with this is limited and the optimum regimen is not really known. Tissue plasminogen
activator (TPA) is now indicated for this purpose and current recommendations are for a 10 mg
bolus over two minutes followed by 90 mg over two hours.